General Internists Research Articles

INTERVENTIONAL CARDIOLOGY 3

The evolution of cardiology over the past 25 years has been dominated by the invention and development of interventional techniques. These techniques offer 'surgical treatment' through transvascular access to the heart, avoiding therefore the classic transthoracic surgical approach. Today, coronary artery disease, valvular heart disease and arrhythmias are accessible to interventional treatments. In this article, a review is given about recent developments and results of interventional treatment for coronary artery disease with special consideration of stenting. This article should help the general practitioner or internist to guide and inform their patients suffering from coronary artery disease.

Outpatient Endocrine Diagnosis and Treatment of Thyroid Diseases and Disorders in a Portuguese Public University Hospital

Background: Thyroid diseases and disorders account for most of the activity of outpatient endocrine departments, but objective data regarding the care of such patients is difficult to find. Knowledge of that data would be fundamental for the planning of those departments and to develop translational research. Methods: A specific database was defined using the Statistical Package for the Social Sciences Program (SPSS IBM, 24th version, 2017) to include the records of all patients assisted by one of us, between January 2005 and December 2016, at the outpatient endocrine department of a public university hospital. Clinical and analytical data regarding the first and last visits was included. Statistical analysis used the same software program. Results: A total of 1,222 patients were included. Diagnostic groups were: 1) Simple nodular goiter (SNG) (46%); 2) Hashimoto’s thyroiditis (HT) (29%); 3) Graves’ disease (GD) (10%); 4) Toxic nodular goiter (TNG) (7%); and 5) Thyroid neoplasia (TN) (5%). After a mean follow-up of 5 years most patients with GD (70%), TNG (77%), HT (67%) and TN (92%) but no patients with SNG (32%) had either received definitive treatment or were being treated. However the euthyroid state was far from universal and not significantly different across groups (62-86%). Conclusions: Continued specialist care of patients with thyroid diseases and disorders is far from perfect. It corrects thyroid dysfunction in most but not all patients and most patients remain on thyroid medications, despite definitive treatment in many. Long-term follow-up of these patients is probably the responsibility of the endocrine team. Otherwise major complications may come to the attention of the specialists only when late recognition is made by general physicians or internists. J Endocrinol Metab. 2019;9(1-2):3-17 doi: https://doi.org/10.14740/jem550

Cognitive Behavioral Therapy and Pharmacotherapy for the Treatment of Tobacco Use Disorder in Primary Care for Resident Physicians.

Though the prevalence of smoking has decreased, it remains the second leading risk for early death and disability worldwide. At the primary care level, the combined use of behavioral interventions and pharmacotherapy has been shown to be more effective in reduction of smoking. Among behavioral interventions, cognitive behavioral therapy (CBT) provides a useful framework for helping patients quit smoking. This 90-minute workshop was led by two facilitators, a general internist who practices as a primary care physician and a clinical psychologist with content expertise in CBT. This pairing provided complementary perspectives to allow for learner engagement. To evaluate the workshop, we used a pre-/postsurvey that was administered at the beginning and the end of the workshop. Participants were asked how often they incorporated (presurvey) and intended to incorporate (postsurvey) CBT as part of smoking cessation counseling in their clinical practices. There was a statistically significant change in learners' perceived usefulness of CBT for smoking cessation from pre- to postworkshop. Our workshop is a unique contribution to the literature. Limitations of our study include not knowing the long-term effect of knowledge acquisition or decay. Our future direction will be to produce training that applies CBT to other common chronic diseases that have a huge behavioral component in primary care, such as insomnia, chronic pain, and obesity.

Internet-Associated Health Anxieties in Primary Care - Results of a Survey among General Practitioners and Primary Care Internists in Hesse

It may happen that extensive internet search leads to health anxiety in patients, which solidify in the long term. Dealing with such 'cyberchondria' presents a special challenge for the physician. The study highlights general medical attitudes and experiences with regard to patients who are increasingly searching the Internet for symptoms, illnesses or therapies. Particular emphasis will be given to persons who develop health anxieties due to previous Health information on the Internet. It will be determined which procedures make sense in order to respond appropriately to patients with internet-related health concerns. In the course of a written survey, a total of 844 general practitioners and primary care internists in southern Hesse and additionally in the rural districts of Gießen, Marburg-Biedenkopf, Kassel and the city of Kassel were interviewed between April 20 and June 20, 2018. Two-thirds of respondents assume that 15 % or more of their own patients confront them with the results of their own internet search. 73 % see the emergence of internet-related health anxiety as an increasing problem in patient care. Against this background, the respondents predominantly see negative effects caused by online self-information (psychological stability, expectations towards the doctor). Almost one of five doctors (18 %) has already experienced the termination of care relationships due to an extensive internet search by the patient. In order to respond to unsettled or frightened patients, the physicians surveyed rely on a detailed explanation of the diagnosis and/or therapy and recommend certain websites that they consider to be reputable. The authors argue that the online information search should be actively discussed in the patient interview in order to prevent possible negative effects on the doctor-patient relationship. Accordingly, it would be worth considering to extend the medical history by the dimension of online self-information.

PTSD and Trauma-Informed Care in the Long-Term Care Setting

PTSD and Trauma-Informed Care in the Long-Term Care Setting

The primacy of ultrasound in the assessment of muscle architecture: precision, accuracy, reliability of ultrasonography. Physiatrist, radiologist, general internist, and family practitioner's experiences.

With high-resolution real-time ultrasonography we investigated the muscle architectural parameters of vastus lateralis in healthy volunteers. We determined the reproducibility and validity of ultrasonography and the role of the ultrasonographer in assessing muscle architecture. We proposed the most appropriate clinical parameters for objective measurements and an ultrasound protocol of muscle architecture. We conducted an intraobserver and interobserver study. We investigated 21 healthy male volunteers. The subjects were independently evaluated by four different operators using high-resolution real-time ultrasonography. To assess the reproducibility of ultrasound examinations, four operators repeated measurements using the same ultrasound device. Muscle thickness, muscle volume, muscle fiber pennation angle, and subcutaneous adiposity of the vastus lateralis muscle were measured. Intra-observer (ICC 0.92-0.97), interobserver (ICC 0.78-0.92) reproducibility was good to excellent for all measurements. Simple, reproducible, non-invasive ultrasound measurements of muscle structure easily demonstrated differences in muscle morphology. With a protocol and with objective and repeatable measurements, sonographers from different backgrounds could obtain an objective measurement of ultrasound images with little differences and low variability in results, thanks to the upgrading of diagnostic ultrasound imaging and their clinical skills.

Ultrasound-guided Bedside Core Needle Biopsy: A Hospitalist Procedure Team’s Experience

Tissue pathology is integral for the diagnosis of various conditions, especially malignancy. Traditionally, biopsy procedures, including core needle biopsy (CNB), are performed by surgeons or radiologists. With the increasing utilization of point of care ultrasound (POCUS) skills and competence in bedside procedures by general internists, CNB can be safely moved to the patient’s bedside with maintained accuracy and increased cost savings compared to traditional procedural methods. We aim to review the experience of our hospitalist-run medical procedure service in performing these ultrasound-guided procedures at the bedside.

A multifaceted primary care practice-based intervention to reduce ED visits and hospitalization for complex medical patients: A mixed methods study.

BackgroundThe management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices.Methods and findingsAn interrupted time series design and qualitative interviews were used to evaluate a multifaceted intervention, SCOPE (Seamless Care Optimizing the Patient Experience), offered to solo PCPs whose patients were frequent users of the ED. The intervention featured a navigation hub (nurse, homecare coordinator) to link PCPs with hospital and community resources, a general internist on-call to provide phone advice or urgent assessments, and access to patient results on-line. Continuous quality improvement (QI) strategies were employed to optimize each component of the intervention. The primary outcome was the relative pre-post intervention change in ED visit rate for patients of participating practices compared with that for a propensity-matched control group of physicians over the contemporaneous period. Themes were identified from semi-structured interviews on PCP’s experiences and influential factors in their engagement. Twenty-nine physicians agreed to participate and were provided access to the intervention over an 18-month time period. There were a total of 1,525 intervention contacts over the 18-months (average: 50.6±60.8 per PCP). Both intervention and control groups experienced a trend towards lower rates of ED use by their patients over the study time period. The pre-post difference in trend for the intervention group compared to the controls was not significant at 1.4% per year (RR = 1.014; p = 0.59). Several themes were identified from qualitative interviews including: PCPs felt better supported in the care of their patients; they experienced a greater sense of community, and; they were better able to provide shared primary-specialty care.ConclusionsThis multifaceted intervention to support solo PCPs in the management of their complex patients did not result in a reduced rate of ED visits compared to controls, likely related to variable uptake among PCPs. It did however result in more comprehensive and coordinated care for their patients. Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs.

A Medical Record Peer-Review System to Evaluate Residents' Clinical Competence: Criterion Validity Analysis.

In contrast to input evaluation (education delivered at school) and output evaluation (students' capability at graduation), the methods of outcome evaluation (performance after graduation) of medical education have not been sufficiently established. To establish a method to measure the quality of patient care and conduct outcome evaluation, we have been developing a peer review system of medical records. Here, we undertook a pilot study to evaluate the criterion validity of our system by using "evaluation by program directors (supervisors in the hospitals)" as a criterion standard. We selected 13 senior residents from three teaching hospitals. Five reviewers (general internists working in other hospitals) visited the hospitals independently and evaluated five patients' records for each resident based on the previously established sheet comprising 15 items. Independently, program directors of the senior residents evaluated their clinical performance using an evaluation sheet comprising ten items. Pearson's analysis revealed statistically significant correlation coefficients in three pairs of assessments including clinical reasoning (r = 0.5848, P = 0.0358). Bootstrap analysis revealed statistically significant correlation coefficients in additional 5 pairs including history taking (r = 0.509, 95% confidence interval: 0.034-0.847). In contrast, the correlation coefficients were low in some items: r = 0.132 (-0.393-0.639) for physical examination and r = 0.089 (-0.847-0.472) for attitude toward patients. To the best of our knowledge, this is the first study, albeit a pilot one, that investigates the criterion validity of medical record evaluations conducted by comparing the assessments of medical records with those by program directors.

Comparison of the Complexity of Patients Seen by Different Medical Subspecialists in a Universal Health Care System

Clinical experience suggests that there are substantial differences in patient complexity across medical specialties, but empirical data are lacking. To compare the complexity of patients seen by different types of physician in a universal health care system. Population-based retrospective cohort study of 2 597 127 residents of the Canadian province of Alberta aged 18 years and older with at least 1 physician visit between April 1, 2014 and March 31, 2015. Data were analyzed in September 2018. Type of physician seeing each patient (family physician, general internist, or 11 types of medical subspecialist) assessed as non-mutually exclusive categories. Nine markers of patient complexity (number of comorbidities, presence of mental illness, number of types of physicians involved in each patient's care, number of physicians involved in each patient's care, number of prescribed medications, number of emergency department visits, rate of death, rate of hospitalization, rate of placement in a long-term care facility). Among the 2 597 127 participants, the median (interquartile range) age was 46 (32-59) years and 54.1% were female. Over 1 year of follow-up, 21 792 patients (0.8%) died, the median (range) number of days spent in the hospital was 0 (0-365), 8.1% of patients had at least 1 hospitalization, and the median (interquartile range) number of prescribed medications was 3 (1-7). When the complexity markers were considered individually, patients seen by nephrologists had the highest mean number of comorbidities (4.2; 95% CI, 4.2-4.3 vs [lowest] 1.1; 95% CI, 1.0-1.1), highest mean number of prescribed medications (14.2; 95% CI, 14.2-14.3 vs [lowest] 4.9; 95% CI, 4.9-4.9), highest rate of death (6.6%; 95% CI, 6.3%-6.9% vs [lowest] 0.1%; 95% CI, <0.1%-0.2%), and highest rate of placement in a long-term care facility (2.0%; 95% CI, 1.8%-2.2% vs [lowest] <0.1%; 95% CI, <0.1%-0.1%). Patients seen by infectious disease specialists had the highest complexity as assessed by the other 5 markers: rate of a mental health condition (29%; 95% CI, 28%-29% vs [lowest] 14%; 95% CI, 14%-14%), mean number of physician types (5.5; 95% CI, 5.5-5.6 vs [lowest] 2.1; 95% CI, 2.1-2.1), mean number of physicians (13.0; 95% CI, 12.9-13.1 vs [lowest] 3.8; 95% CI, 3.8-3.8), mean days in hospital (15.0; 95% CI, 14.9-15.0 vs [lowest] 0.4; 95% CI, 0.4-0.4), and mean emergency department visits (2.6; 95% CI, 2.6-2.6 vs [lowest] 0.5; 95% CI, 0.5-0.5). When types of physician were ranked according to patient complexity across all 9 markers, the order from most to least complex was nephrologist, infectious disease specialist, neurologist, respirologist, hematologist, rheumatologist, gastroenterologist, cardiologist, general internist, endocrinologist, allergist/immunologist, dermatologist, and family physician. Substantial differences were found in 9 different markers of patient complexity across different types of physician, including medical subspecialists, general internists, and family physicians. These findings have implications for medical education and health policy.

Monoclonal Gammopathy of Undetermined Significance (MGUS): Indications for Pre-Diagnostic Testing, Subsequent Diagnoses, and Follow-up Practice

Introduction: MGUS is generally an incidental finding in the diagnostic work-up for clinical signs and symptoms suggestive of lymphoplasmacytic malignancies (multiple myeloma, light chain amyloidosis, and Waldenström macroglobulinemia), which are relatively rare (<35,000 annual new cases in the US). While much is known about the natural history of MGUS, information regarding the pre- and post-diagnostic part of MGUS patient care is lacking. Our study objectives were to determine the following: 1) indications for monoclonal protein testing; 2) subsequent diagnoses found for those indications; 3) specialty of ordering clinicians; 4) follow-up patterns after MGUS diagnosis.Methods: We identified MGUS patients residing in southeastern Minnesota who were diagnosed from 2011-2014 and followed at the Mayo Clinic. Medical records were reviewed to confirm the diagnosis and obtain relevant clinical data. Laboratory tests and visits were identified using Current Procedural Terminology-4th edition (CPT-4) codes from billing data. We defined a follow-up visit as: 1) any face-to-face encounter linked to MGUS diagnosis 30 days after the date of MGUS diagnosis regardless of whether ancillary test was performed or not; and 2) MGUS-specific tests or laboratory tests linked to an MGUS diagnosis claim performed without a face-to-face encounter. Based on the Mayo Clinic MGUS risk stratification model, we classified our cohort into either low-risk or non-low risk. Criteria for low-risk used were: serum monoclonal protein <1.5 g/dL, IgG subtype, and normal serum free light chain ratio. Follow-up patterns were analyzed according to year of diagnosis, demographics, and the specialty of clinicians performing the follow-up.Results: 330 MGUS patients were included in the study. The median age at diagnosis was 73 years (range, 21-98) and most were males (59.7%). The common indications for monoclonal protein studies were neuropathy (19.6%), kidney disease (13.6%), anemia (12.7%), bone symptoms/signs (12.7%), cutaneous disorders (5.8%), congestive heart failure (4.8%), and hypercalcemia (2.7%). The most common subsequent diagnoses for these indications were neuropathy not otherwise specified (NOS;100%), chronic kidney disease NOS (35.5%), anemia of chronic kidney disease (19%), osteopenia/osteoporosis (45.2%), congestive heart failure NOS (57.1%), and dermatitis NOS (100%), respectively. The practice specialties that most commonly diagnosed MGUS were internal medicine (31.3%), neurology (13.7%), nephrology (10.3%), family medicine (6.1%), and hematology (5.8%).Low risk MGUS comprised 44.8% of the cohort. After a median follow-up of 53.5 months (range, 13.0-77.4; IQR, 40.8-77.4), the total number of follow-up visits was 937. Majority (85.5%) of the visits were a combination of office visit with laboratory testing, while the rest were either office visit (11.2%) or laboratory tests (3.3%) only. The distribution of patients by mean interval between visits was: every <6 months (7.9%); every 6-12 months (19.4%); every 13-24 months (15.2%), and every >24 months or no follow-up at all (57.6%). The follow-up patterns did not change significantly (Kruskal Wallis; P=0.6759) over time (Figure 1) and were similar when age groups were compared (Figure 2; P=0.1328). However, males were followed more frequently than females (P=0.0365). Among patients 80 years and older, 32.1% continued to be followed at least once every 2 years (Figure 2). Hematologists were more likely than non-hematologists to follow MGUS patients regardless of the risk category (Figures 3-4). Among low risk patients, 31.1%, 22.2%, 20.7%, and 19.1% had at least one follow-up during years 2, 3, 4, and 5, after MGUS diagnosis (Figure 3).Conclusions: Approximately 1/3 of MGUS diagnoses were made during the evaluation of signs and symptoms not related to lymphoplasmacytic malignancies. The subsequent diagnoses found were a wide variety of common diseases. Most MGUS diagnoses were made by general internists, neurologists, and nephrologists. Follow-up practices varied between hematologists and non-hematologists. Nearly 1/3 of the oldest old patients continued to have follow-up, despite limited life expectancy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Engaging Patients in Clinical Trial Planning: Exploring the Concept of a Minimal Clinically Important Difference Among Patients with Obstetrical Antiphospholipid Syndrome

INTRODUCTIONWomen with antiphospholipid syndrome are at increased risk of pregnancy loss. A large randomized controlled trial is still needed to confirm or refute the efficacy of low-molecular-weight heparin (LMWH) and aspirin (ASA) prophylaxis during pregnancy in women with antiphospholipid syndrome (APS) and past pregnancy loss. The minimal clinically important difference (MCID) is a statistical concept that quantifies the smallest amount of benefit from a treatment that a patient would identify as important, and is used to adequately power clinical trials. When planning a clinical trial, the MCID is most often determined by specialists in the field. How patients make sense of MCID as a concept, and how patients' perceptions of MCID compare to physician responses is unknown. In a challenging and high stakes situation, understanding different patients' perspectives must be considered when planning a large clinical trial. METHODSConsecutive patients were approached from a specialty Thrombosis clinic and from the TIPPS (Thrombophilia in Pregnancy Prophylaxis Study) screening logs between January 2017 and March 2018 in Ottawa, Canada to complete a survey and interview. Patients were eligible if they met the revised Sapporo/Sydney laboratory criteria for antiphospholipid syndrome and had at least 1 late pregnancy loss or 2 early losses (<10 weeks gestation). A similar survey was distributed to 350 specialists identified through 5 professional organizations between May-Sept 2016. Both patient and physician groups had access to an introductory video. The mean MCID between the patient group and physician group was compared using an independent t-test, with p<0.05 being significant. Patient interview data were collected and analysed iteratively, in keeping with constructivist grounded theory methodology. RESULTSThere were 22 (33%) patients who completed surveys and 10 patients who completed semi-structured interviews. Among the physician group, 72 (20.6%) responded to the survey, including obstetricians (34.7%), hematologists (26.4%), general internists (18%), maternal fetal medicine specialists (6.9%) and other specialties (12.6%). Assuming a live birth rate of 60% in the ASA alone arm, the mean MCID answered by physicians was 11.6% (range 5-25%, SD 5.2), compared to the mean MCID answered by patients was 10.0% (range 5-20%, SD 6.4) (p=0.28). The mean number needed to treat (NNT) answered by both physicians and patients was 16. In the majority of cases from both groups, the related concepts of MCID and NNT did not match statistically (i.e. an MCID of 15% is a NNT of 7).An overarching theme from the patient survey comments and interviews was that statistics were somewhat irrelevant. The majority of women thought that “any increase in a chance of live birth” was worth it. However, there was variation in patient responses where some women would only accept a certain success rate of LMWH to justify its use because of drug cost or side effects. Some women acknowledged that they would not use LMWH themselves, but still advocated for other patients to have the option of LMWH use for a chance of a live birth. CONCLUSIONThe mean MCID and NNT were similar between patient and physician groups. The low mean MCID and NNT values likely reflect the importance of the outcome studied (avoiding pregnancy loss) and the perceived safety of the proposed interventions of LMWH and/or ASA, which is supported by qualitative data from patient interviews. While the MCID and NNT responses were similar among physicians and patients, the understanding of statistics was somewhat limited in both groups. By better understanding patients' rationale and beliefs about LMWH use, we can better engage them in clinical trial planning and patient care and ensure that we are performing research that is relevant to patients. DisclosuresSkeith:Leo Pharma: Honoraria; CSL Behring: Research Funding. Rodger:Biomerieux: Research Funding.

Saskatoon Urban Hospital Frozen Plasma Utilization and Appropriateness Audit

Plasma is a blood component frequently used in inappropriate clinical contexts. A 2013 frozen plasma utilization audit in Ontario found that 52% of orders for plasma were inappropriate, while plasma requested for appropriate indications was frequently under-dosed (less than 10 mL/kg administered). Local trends of plasma utilization have not previously been audited. We hypothesized that hospital sites within the former Saskatoon Health Region would have similar rates of inappropriate plasma transfusion and under-dosing as reported by other recent Canadian audits.This retrospective, quality improvement audit was completed evaluating transfused units of fresh frozen plasma and frozen plasma (collectively known as plasma), given between January and September 2017 at the two largest tertiary care hospitals in Saskatoon, Saskatchewan - Royal University Hospital (RUH) and St. Paul's Hospital (SPH). Data collected included: patient demographics, indication for plasma transfusion, plasma dose, coagulation parameters pre- and post-transfusion, specialty of ordering physician, location of transfusion, and concurrent vitamin K use.Appropriateness of plasma utilization was judged according to the Ontario Clinical Practice Recommendations for the Use of Frozen Plasma. Appropriate indications for plasma transfusion included: massive hemorrhage, intraoperative coagulopathy during cardiac surgery, and patients with active bleeding or need for invasive procedures with laboratory evidence of coagulopathy (INR [International Normalized Ratio] ≥ 1.5). Inappropriate indications for plasma transfusion included: correction of laboratory evidence of coagulopathy in the absence of bleeding or need for invasive procedures, reversal of warfarin when Prothrombin Complex Concentrate (PCC) was available, reversal of other anticoagulants, and an INR of 1.5 or less or for whom the INR was unknown. Plasma transfusion to patients with INR of 1.5 or less or with an unknown INR was not considered inappropriate in cases of massive hemorrhage. According to the predefined criteria, each plasma transfusion during our study period was individually reviewed and classified as appropriate or inappropriate.A total of 270 adult and pediatric patients received plasma transfusion during our study period. Patients receiving plasma for therapeutic plasma exchange were excluded. Final analysis included 244 patients, representing 392 transfusion events and 891 units of plasma. Among adult patients at RUH and SPH, 50.5% of plasma transfusions were judged to be inappropriate. The most common inappropriate indication in adult patients (26.5%) was plasma transfusion to patients with an INR of 1.5 or less, or for whom INR was not measured (6.3%). Despite availability of PCC, 5% of plasma orders for adults were for the reversal of warfarin. The average plasma dose ordered for adults was 2 units per transfusion event, which is unlikely to be an appropriate dose for an average sized adult. In adult patients, transfusion of plasma was requested primarily by: critical care physicians (28.6%), cardiac surgeons (16.0%), and general internists (15.3%). Among pediatric patients at RUH, 79.8% of plasma transfusions were judged to be inappropriate, with the most common inappropriate request in pediatric patients (38.5%) cited as hemodynamic support without coagulopathy or massive hemorrhage.Our study demonstrated that the rate of inappropriate plasma transfusion at two major Saskatoon urban hospital sites was similar to that recently published in Ontario. It is reassuring that plasma transfusion for warfarin reversal was found to be only 5%, suggesting broad awareness of PCC availability. Plasma transfused to adults was found to frequently be under-dosed, suggesting patients are being exposed to the potential risks of plasma transfusion with limited clinical benefit. These results highlight plasma transfusion utilization and appropriateness as an area of educational need among both adult and pediatric clinicians. Implementation of strategies including local clinical practice guidelines for plasma transfusion, plasma order screening by the transfusion medicine laboratory, or a plasma transfusion order set may optimize plasma utilization and enhance patient safety by reducing unnecessary patient exposure to plasma transfusion. DisclosuresNo relevant conflicts of interest to declare.

Implantable Cardioverter Defibrillator mHealth App for Physician Referrals and eHealth Education: ICD-TEACH Pilot Study.

BackgroundMobile health (mHealth) decision tools for implantable cardioverter defibrillator may increase physician knowledge and overall patient care.ObjectiveThe goals of the ICD-TEACH pilot study were to design a smartphone app or mHealth technology with a novel physician decision support algorithm, implement a direct referral mechanism for device implantation from the app, and assess its overall usability and feasibility with physicians involved in the care of patients with an implantable cardioverter defibrillator.MethodsThe initial design and development of the mHealth or smartphone app included strategic collaboration from an information technology company and key stakeholders including arrhythmia specialists (electrophysiologists), general cardiologists, and key members of the hospital administrative team. A convenience sampling method was used to recruit general internists or cardiologists that refer to our local tertiary care center. Physicians were asked to incorporate the mHealth app in daily clinical practice and avail the decision support algorithm and direct referral feature to the arrhythmia clinic. Feasibility assessment, in the form of a physician survey, was conducted after initial mHealth app use (within 3 months) addressing the physicians’ overall satisfaction with the app, compliance, and reason for noncompliance; usability assessment of the mHealth app was addressed in the physician survey for technical or hardware problems encountered while using the app and suggestions on improvement.ResultsA total of 17 physicians agreed to participate in the pilot study with 100% poststudy survey response rate. Physicians worked in an academic practice, which included both inpatient and ambulatory care. System Usability Scale was applied with an average score of 77 including the 17 participants (>68 points is above average). Regarding the novel physician decision support algorithm for implantable cardioverter defibrillator referral, 11% (1/9) strongly agreed and 78% (7/9) agreed that the algorithm for device eligibility was easy to use. Only 1 patient was referred through the direct referral system via the mHealth app during the pilot study of 3 months. Feasibility assessment showed that 46% (5/11) strongly agreed and 55% (6/11) agreed that the mHealth app would be utilized if integrated into an electronic medical record (EMR) where data are automatically sent to the referring arrhythmia clinic.ConclusionsThe ICD-TEACH pilot study revealed high usability features of a physician decision support algorithm; however, we received only 1 direct referral through our app despite supportive feedback. A specific reason from our physician survey included the lack of integration into an EMR. Future studies should continue to systematically evaluate smartphone apps in cardiology to assess usability, feasibility, and strategies to integrate into daily workflow.

Rhetorische Ausgestaltung von Äußerungsreparaturen in der Arzt-Patient- Interaktion

Abstract Doctor-patient communication is a condensed and solution-oriented interaction. Repairs of what is said and what isn‘t processed properly are especially in these - usually very short - interactions important to get to a common level of knowledge. This is not only crucial for the implementation of the common and targeted interaction, but also for a successful therapy following it. In addition, in some cases repairs are extremely delicate. In this article we will discuss which rhetorical devices the participants use for repair and how these repairs are processed. Not only rhetorical devices differ, but also processing of the repairs in individual interactions. Data are based on various corpora of medical communication with dyadic and triadic structure of general practitioners, internists, urologists and pediatricians from Germany and Korea.

Prevalence, Mortality, and Indicators of Health Care Supply-Association Analysis of Cardiovascular Diseases in Germany.

Introduction: There are regional differences in the morbidity of major cardiovascular disease between the 16 federal states of Germany. An association between the morbidity and the health care supply has been described in international studies. The aim of the present analysis was to examine the relationship between the prevalence or mortality of major cardiovascular disease and several key indicators of health care supply in Germany.Methods: Life expectancy and the proportion of over 65-year old persons were included as characteristics to depict the general health. Indicators of health care supply were the number of general practitioners, internists, and cardiologists, number of internal medicine and cardiology beds, chest pain units (CPU), cardiac catheterization laboratories (CCL) and stroke units. In the form of an ecological analysis, we compared the cardiovascular disease prevalence and mortality with these indicators and performed a weighted linear regression.Results: Regional variations between the federal states were found in general health and health care supply. The regression analysis yielded significant associations of the prevalence of major cardiovascular disease with the number of internal medicine hospital beds (β = 10.042, p = 0.045), cardiologists (β = −0.689, p = 0.031), and the number of residents per chest pain unit (β = 42,730, p = 0.036). Additionally, the relationship between cardiovascular mortality and also the number of residents per chest pain unit appeared to be significant (β = 4,962, p = 0.002). For all other indicators, no significant association was observed.Conclusions: We detected regional differences in the general health and health care supply between the 16 German federal states as well as several significant associations between cardiovascular morbidity and health care supply indicators. Especially the decreasing number of cardiologists and rising number of residents per chest pain unit with an increasing prevalence of major cardiovascular disease should lead to a discussion about the structure of the Germany health care system, such as the needs-based planning mechanism of physicians. The results of this study may also aid in future development of other health care systems.

Factors associated with participation and completion of a survey-based study

PurposeThe Healthy Work Place (HWP) study investigated methods to improve clinicians’ dissatisfaction and burnout. The purpose of this paper is to identify factors that influenced study enrollment and completion and assess effects of initial clinic site enrollment rates on clinician outcomes, including satisfaction, burnout, stress and intent to leave practice.Design/methodology/approachIn total, 144 primary care clinicians (general internists, family physicians, nurse practitioners and physician assistants) at 14 primary care clinics were analyzed.FindingsIn total, 72 clinicians enrolled in the study and completed the first survey (50 percent enrollment rate). Of these, 10 did not complete the second survey (86 percent completion rate). Gender, type, burnout, stress and intervention did not significantly affect survey completion. Hence, widespread agreement about most moral/ethical issues (72 percent vs 22 percent; p=0.0060) and general agreement on treatment methods (81 percent vs 50 percent; p=0.0490) were reported by providers that completed both surveys as opposed to just the initial survey. Providers with high initial clinic site enrollment rates (=50 percent providers) obtained better outcomes, including improvements in or no worsening of satisfaction (odds ratio (OR)=19.16; p=0.0217) and burnout (OR=6.24; p=0.0418).Social implicationsMore providers experiencing workplace agreement completed the initial and final surveys, and providers at sites with higher initial enrollment rates obtained better outcomes including a higher rate of improvement or no worsening of job satisfaction and burnout.Originality/valueThere is limited research on clinicians’ workplace and other factors that influence their participation in survey-based studies. The findings help us to understand how these factors may affect quality of data collecting and outcome. Thus, the study provides us insight for improvement of quality in primary care.

An Inquiry Into the Early Careers of Master Clinicians

Residents and fellows often seek to emulate master clinician role models; however, the activities these expert clinical faculty pursued early in their careers are not known. We studied the early career clinical experiences and learning behaviors of peer-defined master academic clinicians. We performed a retrospective, qualitative interview study of 17 members of the University of California, San Francisco, Department of Medicine Council of Master Clinicians. Between March 1 and May 31, 2016, we interviewed participants using a semistructured interview guide surveying their early career clinical experiences and learning habits. Interviews were audio-recorded and transcribed. We used a general inductive approach to code transcripts and to identify consistent themes. Of the 28 council members invited to participate, 17 (61%) responded and were interviewed. Participants included 12 men and 5 women, with an average of 27 years in clinical practice (range, 13-50 years). Six participants were general internists, and 11 were internal medicine subspecialists. Based on thematic analysis of interview transcripts, 4 themes of clinical development emerged: (1) consistent learning efforts; (2) rigorous skill development; (3) cultivating habits of mind; and (4) clinically rich environments. Our study describes the early career experiences and learning behaviors of master clinicians. We aggregated key dimensions of the findings into a guide for residents, fellows, and junior clinicians interested in the pursuit of clinical excellence.

A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice.

Background:Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice.Methods:A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed.Results:After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients.Conclusions:The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

General Internists in Pursuit of Diagnostic Excellence

General Internists in Pursuit of Diagnostic Excellence